WHOPackage of Essential Noncommunicable (PEN) disease

interventions for Primary Health Care

FAQs
1. What is WHO PEN?
The WHO package of essential noncommunicable (PEN)disease interventions for primary health care
defines a minimum set of interventions to address major NCDs in primary care. These interventions
are feasible even in low resource settings. Contents of WHO PEN can be adapted to emergency and
humanitarian settings. Countries can expand on the core interventions according to their needs and
resources

WHOPEN is intended to be used by primary care physicians and non-physician health workers involved
in providing NCD services in primary care settings. Use of WHO PEN interventions will require
strengthening of the health system the building blocks as per the context.

2. What are the components of WHO PEN?

WHO PEN has section covering the various aspects of NCD management in primary care.
Disease and programme specific interventions cover the following areas.
1. Cardiovascular diseases
• CVD risk assessment and management
• Hypertension management
2. Diabetes
• Management of Type 2 diabetes
3. Chronic respiratory diseases
• Management of asthma and exacerbation
• Management of COPD and exacerbation
4. Cancer early diagnosis
• Common cancer symptoms and signs
• Cervical cancer
• Breast cancer
5. Healthy lifestyle counselling
• Self care among patients with cardiovascular disease, diabetes or respiratory disease
6. Palliative care
• Practice points for palliative care
In addition, a section on adapting WHO PEN provides a stepwise approach for implementing these
components in primary care. Tools and resources are provided in the annex.

3.What are the considerations in NCD health service organization?

a. NCDs need long term care throughout life, unlike communicable diseases where the
care is usually needed for a finite period.
b. NCDs are often asymptomatic to start with and this makes early diagnosis of the
disease difficult
c. NCD service organization entails a well-defined service delivery model with clarity on
roles and responsibilities.
 d. Team based care and task sharing are important concept in NCD care. Enabling
environment including the required administrative approvals are needed to make this
happen.
e. Key features for NCD service organization include:
• Health services
o A defined set of interventions depending on the local context
o Decentralized care delivery
o Use of standard protocols / local clinical guidelines approved by the authorities
o Uninterrupted supply of essential diagnostics and medicines
• Human resources
o Adequate staffing to deliver the services
o Continued capacity building
o Supportive supervision and mentoring
o Effective communication
o Team based care
• Referral and follow up mechanism
o Ensure adherence to medications
o Adherence to follow up
o Established referral chain
o Community linkages
• Monitoring of quality indicators

4.What is WHO HEARTS technical package? How is it aligned to PEN?

The HEARTS technical package provides a strategic approach to improving cardiovascular

management in primary health care settings. It comprises six modules:
H- Healthy lifestyle counselling
E- Evidence based treatment protocols
A- Access to essential medicines and technology
R-Risk-based CVD management
T-Team-based care
S-Systems for monitoring

• WHOPEN has all the elements of WHO HEARTS package. The focus of HEARTS is on
cardiovascular diseases while PEN includes NCD interventions in other areas.
o WHO PEN has sections from the specific areas of the HEARTS modules as indicated below:
o Cardiovascular component from HEARTS E and HEARTS R modules
o Diabetes component is from HEARTS- Diabetes module
o Healthy lifestyle counselling from HEARTS H module
o Monitoring from HEARTS S is module
5.What is total CVD risk assessment and management?
• CVD Risk prediction is the process of identifying individuals based on the probability that they
might develop a CVD event/fatality (myocardial infarction or stroke) in the next 10 years. Total
CVD risk includes all CVD events (both fatal and nonfatal).
• The first WHO/ISH cardiovascular risk prediction charts were developed in 2007.
• The CVD risk prediction charts have been updated in 2019 and are presented in WHOPEN app
as lab-based and non-lab-based CVD risk calculators.

6.What are the changes in CVD risk management (including in hypertension

management) in the updated WHO CVD risk charts from the previous WHO/ISH
charts?

• Total CVD risk assessment is a tool to support the integrated management of multiple risk
factors in an individual. However, it is not meant to restrict treatment when indicated in a single
risk factor. It helps in identifying the subgroup of individuals who may not have a high level of an
individual risk factor but is at high risk due to multiple risk factors. This is a decision support tool
to be used by the health provider.
• Countries may set different thresholds for initiating treatment, based on the distribution
of CVD risk in the population.
The changes in CVD risk categories and indications for treatment among technical packages are
summarized in the table below:

WHO PEN 2013 HEARTS E HEARTS R -module PEN module WHOPEN App-2021
module-2018 2020 updated -
2020

CVD risk levels Risk levels: No risk level Risk levels changed Risk levels Risk levels as in HEARTS
categories <10 <5 as in R
10 to <20 5 to <10 HEARTS R <5
20 to <30 10 to <20 <5 5 to <10
≥30 ≥ 20 5 to <10 10 to <20
10 to <20 ≥ 20
≥ 20
Hypertension HTN treatment All people NO CHANGE from In CVD risk In CVD risk <10% HTN
medication for indicated if risk with BP WHOPEN 2013: <10% HTN treatment indicated if
BP≥140/90 mmHg more than 20% ≥140/90 CVD risk >10 % treatment BP ≥140/90 mmHg is
with persistent mmHg (equivalent to CVD risk indicated if persistent
BP ≥140/90 >20 % of previous WHO/ BP ≥140/90
mmHg ISH chart) mmHg is
HTN treatment persistent
It does not say indicated if risk more
not to treat high than 10% with
BP if risk less persistent BP ≥140/90
than 20% mmHg

Statin The change in recommendation for statins is only because of the new risk categories; however
underlying principle remains the same. Statins are recommended for persons with CVD risk level above
20% (in the previous WHO/ISH charts, statins were recommended at risk 30% and above)
 7. What is the guidance on health education, counseling, and self-care

Counselling for healthy lifestyles involves guiding and supporting patients in making changes in
certain behaviours to reduce the risk of NCDs. Counselling patients on self-care can be integrated
into existing care structures. All interactions with patients can be seen as opportunities to
understand and improve the self-care strategies.

a. Educate the person to:

1. Stop tobacco and avoid harmful use of alcohol
2. Eat a ‘heart healthy’ diet
3. Be physical active and
4. Adhere to treatment
b. Self-care
1. Al patients with NCDs perform some level of self-care. Health workers should be
equipped to support and promote self-care
Health workers should use their skills, resources and patient preferences to develop
plans and group education programmes may offer a cost-effective strategy.

8. What are the consideration in monitoring of NCD interventions in the health

system
• Given the chronic nature of the diseases, regular clinical audits can help to
improve the skills and capacity and address challenges in services.
• It is preferable to have a computerized system with unique ID, to ensure long term
follow up and avoid duplication of records
• Certain indicators have been proposed for management of hypertension and diabetes.
They can be used to track the performance of the program
• Individual clinical monitoring, facility based assessment and population based indicators
are helpful in programme monitoring.

9. How can WHOPEN be adapted into health systems?

WHOPEN can be adapted using a stepwise approach, whether to prevention, surveillance, or

management. WHOPEN offers a framework to help countries get started and to focus on what is
practical, considering the available human, financial and other resources.
A stepwise approach to implementation of WHO PEN is presented below:

1. Engage stakeholders
a. Hold introductory meetings with stakeholders
b. Obtain ministry of health endorsement
c. Establish technical working group
d. Identify demonstration site
2. Assess the current status of NCDs
a. Desktop review of existing plans, policies (including public policies) and guidelines that
contribute to NCD control in the country
b. Assess the capabilities of the primary care health infrastructure
c. Review and summarize existing NCD services at all levels of the health system
 d. Conduct a strength, weaknesses, opportunities, threats (SWOT) analysis
3. Develop a service delivery model for PHC for NCDs based on WHO PEN
4. Capacity building
a. Conduct training for health workers on agreed upon model and protocols
b. Host ongoing in-service trainings
c. Appoint mentors

d. Develop supervision checklists and ensure supportive supervision is done at regular

intervals
5. Monitoring and evaluation
a. Define indicators and existing tools for measurement
b. Establish a monitoring process
6. Review and plan for scale up
a. Review and evaluate WHO PEN implementation at demonstration sites
b. Cost WHO PEN package implementation
c. Finalise service delivery model
d. Develop a plan for phased scale up

10. What is WHOPEN App?

WHOPEN app is developed as a tool to facilitate the implementation of WHO Package of
Essential Noncommunicable (PEN) disease interventions for primary health care.
• It is intended to be used by a health care provider.
• It brings together the guidelines and protocols that are adaptable to local settings
and able to empower primary care physicians as well as allied health care
workers to contribute to NCD management.
• WHOPEN app contains a CVD risk calculator for lab-based and non-lab-based
WHO CVD risk.
• It is not meant to be exhaustive or prescriptive, but rather to be an important
first step for integration of NCD management into primary health care.
• Tools for adapting the package and capacity building resources which includes
presentation slides, posters, assessment questions are also included.
• The WHOPEN app does not collect any personal information about the user

The application is available for Android and IOS Platforms, click on the link below
to download the App
• Android https://play.google.com/store/apps/details?id=org.who.WHOPEN
• iOS– https://apps.apple.com/us/app/whopen/id1566338877

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